Cecille Joan Avila is a Policy Analyst at Boston University School of Public Health. She tweets at @cecilleavila.
“Vulnerable” is often used to avoid the discomfort associated with naming structural racism as the true root cause of many public health problems. Sometimes referring to those who are clinically vulnerable to disease because of their age is appropriate, but generally calling an entire population (or sub-population) vulnerable is not.
Simply put, structural racism refers to the normalization of discriminatory practices towards people (read: Black and Brown people) that restrict their opportunities and disadvantage them. In terms of public health, this results in poorer health outcomes or higher rates of mortality and morbidity.
A prime example: The US has some of the worst maternal mortality rates in the Global North and some races or ethnicities are more vulnerable than others.
Here lies the crux of why “vulnerable” is so easily and frequently misused. It’s a succinct yet vague way to draw focus on something that needs attention, money, resources, or all three. But its vagueness is harmful because it erases or obscures the full truth. It is dangerous to rely on the reader to “fill in the blank” of what a person is vulnerable to, especially because doing so invites stereotypes and implicit biases cultivated within an inherently racist society.
That public health perpetuates the problematic use of the term “vulnerable” is evident when we look at our own publications. A recent study of the word “vulnerable” and its use in Canadian and American public health journals found that more than a third of articles used the word in a vague way that disguises the actual cause of preventable, poor health, leaving readers to guess the specifics of who is vulnerable, what they are vulnerable to, and why.
Thanks to extensive media coverage and personal testimony from celebrities like Serena Williams, we know that “some races or ethnicities are more vulnerable than others” is a poor stand in for something else: Black women are more likely to die in pregnancy or suffer complications in childbirth than their white counterparts because of structural racism.
Black women die preventable deaths not just because they are devalued and dismissed by individual providers, but because of a society and institutions built on 400 years of oppression. Considering that American medicine and slavery evolved together and the history of unethical experimentation on Black people in this country, any skepticism of the medical system is understandable. Even beyond health care, discriminatory housing practices have pushed Black Americans out of their homes, not only prohibiting them from acquiring generational wealth, but also forcing them into geographic areas that make it difficult to access adequate health care. This puts them in poorer health at the onset of their pregnancy.
But we can only change what we can identify. If we disguise racism with the term “vulnerable” we won’t contemplate it, we won’t confront it. This is how we end up with well-intentioned programs and policies to try and address maternal mortality (patient-centered homes, subsidizing the cost of doulas with federal dollars, requiring implicit bias training for doctors) that while helpful, never go deep enough to tackle the fundamental driver.
Completely striking the word “vulnerable” from the public health lexicon — were that even possible — won’t solve everything. But it will allow us to start focusing on the real problems we want to change.
Perhaps some find it easier to say and write “vulnerable” because acknowledging complicity in maintaining structural racism is uncomfortable. It’s uncomfortable to acknowledge we are trying to fix a problem we created and sustained, but we need to get used to that discomfort if we want lasting change.
We should commit to using direct language, explicitly naming disparities and defining exactly who is most at risk of harm from a specific cause, but there’s more to do than just widening our vocabulary.
Public health practitioners can also begin to undo some of the harms we have inadvertently perpetrated with vague terminology and obscuring our own biases. We can amplify Black and Brown voices in academia, letting them lead and teach their lived experiences should they choose to. We can recruit population samples reflective of minorities in this country, so we can stop generalizing to whiteness.
Once we stop using “vulnerable” as a euphemism, we will be a step closer to acknowledging that racism is not a driver of social determinants of health. It is one.